Issue Brief

Defining Children With Medical Complexities

Who are children with medical complexities?

These children should only be referred to as medically complex children, children with medical complexities, or children with medically complex conditions.

Children with medical complexities require the highest level of services and support from children’s hospitals due to the intensity of care and breadth of pediatric specialists required to care for their conditions. There are approximately 3 million of these children in this country, and almost all of them are cared for in children’s hospitals. And the population is growing.

Children with medical complexities are often enrolled in Medicaid. Based on initial estimates of Medicaid data, 6 percent of child enrollees fall into this category, and they represent 40 percent of the Medicaid health care spend for children.

How are they defined?

Using the 3M™ Clinical Risk Group categories, these children can be defined as those that fall into CRG categories 5 through 9* --a portion of children in lifelong chronic, complex chronic children, and children with malignancies.

They are children with significant chronic conditions in two or more body systems or those with a single dominant chronic condition.